Physicians' Academy for Cardiovascular Education

Lower 1-year LDL-c after revascularization reduces MACCE in T2DM and CHD

Influence of LDL-Cholesterol Lowering on Cardiovascular Outcomes in Patients With Diabetes Mellitus Undergoing Coronary Revascularization

Literature - Farkouh ME, Godoy LC, Brooks MM, et al. - J Am Coll Cardiol 2020, 76: 2197-207,

Introduction and methods

For management of patients with coronary heart disease (CHD) and T2DM, guidelines recommend intensive lifestyle changes together with aggressive, multifactorial secondary prevention, consisting of optimal medical therapy (OMT) and most appropriate revascularization strategy [1]. Coronary artery bypass grafting (CABG) added to OMT has demonstrated to lower major adverse cardiac or cerebrovascular events (MACCE) compared to OMT alone [2] or percutaneous coronary intervention (PCI) plus OMT [3] in patients with T2DM and stable CHD in need of revascularization.

Despite this clear recommendations, there is limited knowledge on impact of LDL-c reduction following revascularization in patients with T2DM. Therefore, this study investigated the influence of LDL-c levels at 1 year follow-up following a coronary revascularization procedure on incidence of long-term MACCE in patients with T2DM. More specifically, it was assessed whether there was a graded effect of achieved LDL-c on outcomes and whether there was a differential effect of LDL-c reduction according to assigned intervention strategy (revascularization with PCI, CABG or OMT alone).

Patient-level data from 3 large randomized trials of coronary revascularization were pooled (BARI 2D, COURAGE and FREEDOM [2-4]). The study population consisted of 4050 patients. Patients were categorized according achieved LDL-c levels after the first year of follow-up (<70 mg/dL [n=1398, 34.5%]; 70 and <100 mg/dL [n=1711, 42.2%]; and ≥100 mg/dL [n=941, 23.2%]).1348 Patients (33.3%) were assigned to OMT group, 990 (24.4%) to CABG plus OMT and 1712 (42.3%) to PCI plus OMT. Primary outcome was 4-year rate of the MACCE composite: all-cause mortality, nonfatal MI or nonfatal stroke. Subsequent revascularization was a secondary endpoint. Median follow-up in the pooled cohort was 3.9 years (Q1 to Q3: 3.0-4.0) after the 1-year assessment.

Main results


This analysis of pooled data from 3 trials demonstrated that T2DM patients undergoing revascularization with achieved 1-year LDL-c levels ≥100 mg/dL had higher 4-year risk of MACCE and likely higher risk of revascularization compared to patients with LDL-c <70 mg/dL, showing the importance of LDL-c control in the first years after revascularization procedure. In T2DM patients undergoing PCI LDL-c lowering is important, because when compared to OMT alone, reduction of MACCE was only observed in those with 1-year LDL-c <70 mg/dL. CABG was superior to OMT for all LDL-c strata and CABG was superior to PCI for LDL-c strata >70 mg/dL.


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